Veteran Report Form

Last Name ____________________________       First Name ____________________________________  MI _______

Birth Date _____________________________        Place of Birth _______________________________________________ 

Date Entered Service ____________________    Date Discharged/Retired ____________________________________

Branch of Service ________________________   Unit ________________________________________________________

War ___________________________________Foreign Service _________________________________________________

Rank __________________________________ Highest Award _________________________________________________

Last Assignment _______________________________________________________________________________________

Additional Information: _________________________________________________________________________________

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If deceased:  Date of Death ________________ Place of Burial _______________________________________________

Source of information:  __________________________________________________________________________________

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(If individual, give name, address, and telephone number/e-mail)

Recorded by:________________________________________________________Date:_________________________

Please return to: Miamisburg Historical Society, P. O. Box 774,  Miamisburg Ohio  45342

or Market Square Building on Wednesday or Saturday between 1:00 P.M. and 4:00 P.M.